Home-based primary care allows health care providers to spend more time with their patients, perform assessments in a patient’s home environment, and assume greater accountability for all aspects of the patient’s care. This focus on timely and appropriate care is designed to improve the overall quality of care and quality of life for patients served, while lowering health care costs by forestalling the need for care in institutional settings.
The Independence at Home Demonstration provides chronically ill patients with a complete range of primary care services in the home setting. Medical practices led by physicians or nurse practitioners provide primary care home visits tailored to the needs of beneficiaries with multiple chronic conditions and functional limitations. The Demonstration also tests whether home-based care can reduce the need for hospitalization, improve patient and caregiver satisfaction, and lead to better health for beneficiaries and lower costs to Medicare.
The Independence at Home Demonstration is authorized by Section 3024 of the Affordable Care Act. The demonstration began in 2012 and was originally authorized for three years. It was subsequently extended for two additional years through September 30, 2017 by the Medicare Independence at Home Medical Practice Demonstration Improvement Act of 2015. The Bipartisan Budget Act of 2018, enacted February 9, 2018, extended the demonstration for an additional two years through September 30, 2019.
Summary of Results from Performance Year 2
In the second performance year of the demonstration, 10,484 beneficiaries were enrolled in the 15 participating practices. For the second performance year, all 15 of the Independence at Home practices improved performance from the first performance year in at least two of the six quality measures for the demonstration. Four practices met the performance thresholds for all six quality measures.
In the original release of Performance Year 2 results in August 2016, CMS stated that the 15 participating practices saved $10,612,506 in aggregate, and that seven participating practices earned incentive payments of $5,719,526 (See Table 1 below).
Table 1. Performance Year 2 Results for Participating Practices (Released in August 2016)
Independence at Home Practice Name
Year 2 Spending Target*
Year 2 Expenditures*
Practice Incentive Payment
Boston Medical Center
Christiana Care Health System
Cleveland Clinic Home Care Services
Doctors Making Housecalls
Doctors on Call
House Call Doctors Inc.
Housecall Providers, Inc.
Northwell Health Care
* The Year 2 Spending Target and Year 2 Expenditures are on a per beneficiary per month (PBPM) basis.
After these results were released, CMS discovered two errors in its work that affected (1) the calculation of Performance Year 2 savings for the revised regression-based methodology and (2) the application of the policy related to overlapping beneficiaries in shared savings models within CMS for the original and revised regression-based methodologies. The revised Performance Year 2 results, reflecting the correction of these errors, are presented in Table 2 below. The corrected analysis found that in Performance Year 2, Independence at Home practices saved, in aggregate, a net of $7,821,374, an average of $89 per beneficiary. Seven participating practices earned incentive payments in the amount of $5,322,343.
Table 2. Corrected Performance Year 2 Results for Participating Practices
Independence at Home Practice Name
Year 2 Spending Target*
Year 2 Expenditures*
Practice Incentive Payment
Boston Medical Center
Christiana Care Health System
Cleveland Clinic Home Care Services
Doctors Making Housecalls
Doctors on Call
House Call Doctors Inc.
Housecall Providers, Inc.
Northwell Health Care
* The Year 2 Spending Target and Year 2 Expenditures are on a per beneficiary per month (PBPM) basis.
Quality Measures
Under the Independence at Home Demonstration, participating practices must meet the performance thresholds for at least three of the six quality measures in order to qualify for the incentive payment. The six measures are:
Shared Savings Methodology Modifications
For the first performance year of the Independence at Home Demonstration, a regression-based methodology was predominantly used to determine demonstration savings. Under the regression-based methodology, CMS derived the savings estimates by making comparisons between the treatment group, or demonstration beneficiaries, and a matched comparison group of beneficiaries identified in CMS’ administrative data who meet the demonstration eligibility criteria and do not receive home-based primary care. For the second performance year of the demonstration, CMS identified potential issues under the regression-based methodology with the comparability between the treatment group and the matched comparison group used in the analysis of the demonstration savings. CMS conducted many analyses concerning the comparability issues.
To construct the comparison group, beneficiaries who met the demonstration eligibility criteria and were statistically similar to the demonstration beneficiaries in their health conditions, activities of daily living (ADL) limitations, and demographic characteristics, such as age and sex, were matched to demonstration beneficiaries. For the second performance year, revisions were made to the detailed health characteristics and other variables used for matching. CMS also revised the approach to measuring characteristics of beneficiaries who continued in the demonstration from its first year into its second year without meeting all of the eligibility criteria again. Finally, changes were made to the selection of beneficiaries in the treatment group used for analysis. Collectively, these changes helped to improve comparability between Independence at Home beneficiaries and their matched comparison group beneficiaries. Participants using the regression methodology in the first performance year had the choice between the original regression methodology and this revised regression methodology for the second performance year.
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